Owensboro Health Twin Lakes Medical Center

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44370 Based on interview, record review, video footage, and review of facility policies, it was determined the facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) for one (1) of twenty-one (21) sampled patients. Patient (P)1 presented to the ED on 04/24/2025, by Emergency Medical Services (EMS) at 3:27 PM, following a motor vehicle collision with rollover. Upon the patient’s arrival at Facility (Fac) 1 the ED Director diverted EMS and P1 to Fac 2 as the hospital was on a “trauma diversion;” however, without first providing a MSE. The findings include: Review of the facility policy, “EMTALA - Emergency Medical Treatment”, last reviewed 08/2023, revealed, “all patients presenting to the emergency department would receive emergency medical treatment.” Per review, “all patients who come to the emergency department for treatment must be given an appropriate” MSE by a qualified medical personnel to determine whether they had an emergency medical condition. Continued review revealed if an emergency medical condition existed, then the hospital “must” provide such further medical examination, and such treatment as might be required to stabilize the medical condition or transfer the individual to another medical facility. Further review revealed, “EMTALA is triggered when a patient comes to the hospital, not just the emergency department, and when the patient requests treatment. Additionally, review revealed when patients came to the emergency department (ED) seeking treatment, they “must be given an appropriate medical screening examination by qualified medical personnel.” Review of the facility’s, “Emergency Operation Plan (EOP)” dated, 11/2024, under “Emergency Code Definitions,” revealed a “Code Yellow” was a disaster. Per review, the facility was to activate response to incidents that required or might require significant support from several departments to continue patient care. Continued review revealed a notification was to be issued that a general internal or external disaster existed and specific instructions were to be given for actions to take to deal with the disaster. Continued review of EOP revealed the “Hospital Staffing Plan,” that noted the hospital was to ensure that essential and critical staff functions were performed for the rapid, effective implementation of any emergency response. In addition, review revealed it was policy to ensure adequate staff were available to perform those critical functions at any time of the day or night. Additional review of the EOP revealed under “Diversion,” it was noted the policy of the facility was to divert patients from the ED only when certain pre-established conditions existed that negatively and profoundly impacted the organization’s ability to provide safe patient care. Per review, diversion was defined as requesting ambulance services to transport patients from outlying counties to a hospital other than Fac 1. Continued review revealed ambulance diversion was to only occur as a result of circumstances that resulted in a disruption of essential hospital services. Further review revealed unstable patients who, in the judgment of the paramedic, might be subjected to increased risk by being transported to another hospital. In a telephone interview on 04/28/2025 at 11:17 AM, the Complainant stated he, the paramedic, and a trainee responded to a motor vehicle collision (MVC) with rollover on the afternoon of 04/24/2025. He stated P1 had been an intoxicated driver of the vehicle that left the roadway and rolled over. The Complainant said upon arrival at the scene P1 had exited the vehicle, was alert and oriented, and was ambulatory. He stated P1 had lacerations to the back of his head and above his right eye that were actively bleeding. The Complainant reported P1’s vital signs had been abnormal and potentially unstable, and he was treated in the ambulance and transported to Fac 1. He stated upon arrival at the facility they were met at the ambulance entrance by the Emergency Department (ED) Director. The Complainant further stated before they were able to remove P1 from the ambulance, the ED Director asked why they brought the patient to their hospital and asked them to transport the patient to a different hospital. Review on 04/29/2025 at 11:40 AM, of the hospital’s (Fac 1’s) video surveillance indicated on 04/24/2025 at 3:27 PM, EMS arrived at Fac 1. During review of the video surveillance, an EMS staff person (the paramedic) was observed to exit from the back of the ambulance and two staff observed to exit from the ambulance’s cab. Continued video surveillance review revealed the EDD observed to come out of the hospital and approach the paramedic, and they have an unheard conversation. Further review of the video surveillance revealed the EMS personnel was observed to get back in the ambulance and leave the facility at 3:33 PM, without observation of P1 being removed from the ambulance. Review of the EMS Patient Care Record, (EMS run report) dated 04/24/2025, revealed the “Narrative Summary,” noted EMS had been dispatched for a single-vehicle accident with rollover. Per review, when EMS arrived on scene a male was standing in the middle of the road as EMS approached. Review revealed P1 reported he had wrecked his car up the road and his head was messed up, and stated “help me.” Continued review revealed, “The patient is ambulatory, mostly steady on his feet, he has an approximately 2-inch laceration to the posterior head area with minor bleeding.” Review revealed P1 was assessed for other injuries, with a strong smell of alcohol coming from the patient, who reported he “drank quite a bit.” Further review revealed P1 was hypertensive with no history of hypertension, and other injuries that included a small puncture cut to the right of his right eye and mild bleeding coming from the right nostril. In addition, review revealed P1 was stable; however, remained hypertensive the transport began. The review revealed EMS staff discussed with P1 that the local hospital had no computerized tomography (CT) capability at the time, with the patient “adamantly” wanting to be transported to Fac 1. Review further revealed P1 told EMS staff, “just have them staple my head up” because “I want to go home.” Review also revealed the ambulance arrived at hospital (Fac 1) where “we were met by the ED Director.” Continued review of the EMS Patient Care Record revealed P1’s blood pressure (B/P) readings were as follows: at 3:07 PM, B/P was 181/108; at 3:14 PM, 186/96; at 3:17 PM, 161/98; at 3:27 PM, 171/81; at 3:36 PM, 192/102; at 3:41 PM, 194 /107; at 3:51 PM, 192/114; at 3:56 PM, 201/113; and at 3:58 PM, the patient’s B/P was 187/109. In interview on 04/29/2025 at 11:55 AM, with the Vice President of Operations (VPO) and the Chief Nursing Officer (CNO), the VPO stated the hospital had been under a “Code Yellow” (Disaster) at the time P1 arrived at the ED. She stated the facility had no Internet services and therefore, had no way to transmit or read the CT scan results after 3:00 PM, when the radiologist’s shift ended. The VPO stated the facility used an “on-call vendor” for having radiology reports read when the radiologist was not available; however, as there was no Internet they could not transmit the reports to have them read. In interview on 04/29/2025 at 3:17 PM, the EMS paramedic stated when “they” arrived at Fac 1 (on 04/24/2025) before she was able to remove the patient from the ambulance, the ED Director met them. The EMS paramedic said the ED Director told them to go to a different hospital and asked them, “why are you bringing him here the CT is down.” She stated she advised the ED Director the patient requested to be brought to that facility. The EMS paramedic reported the ED Director told her P1 would need a CT of his head and the facility’s CT machine was not operable at that time. She said the ED Director told them, as P1 was intoxicated, they should have made the transport decision for him and should have taken him somewhere else. The EMS paramedic reported the ED Director then asked her if the attending physician needed to come out to tell them that they needed to transport P1 to a different hospital as well. She stated she advised P1 of the situation and the patient still wanted to be treated at Fac 1, and was not happy about having to go to another facility (Fac 2). The EMS paramedic said she had been aware Fac 1 was on diversion for trauma; however, P1 was hypertensive and tachycardic and that warranted him being seen by Fac 1. She further stated they were diverted to Fac 2 which was thirty minutes away. Review of “Google Maps “ website (www.google.com/maps) revealed FAC 2 was 34 miles from FAC 1. In interview on 04/30/2025 at 9:02 AM, the Director of Radiology stated on 04/24/2025, there had been an Internet outage which caused the reading of CT scans not to be completed. He said after 3:00 PM results were “sent out” for reading and with no Internet that could not be done. The Director of Radiology stated knowing whether a patient needed to have a CT scan fell on the ED. He stated the facility got their Internet “back up” sometime that evening. In interview on 04/30/2025 at 9:15 AM, the ED Director stated when EMS called in, report was taken by phone and said the information was written down on a note pad. He stated he made the EMS driver aware (on 04/24/2025) that the facility was on diversion and the CT was unavailable. The ED Director said the Medical Director heard that conversation. He stated EMS should have taken P1 somewhere else, and reported he had not been informed the patient had a laceration, elevated B/P and heart rate. The ED Director further stated the facility should follow its trauma protocol, and when asked by the State Survey Agency (SSA) Surveyor if P1 should have received an MSE, he stated “yes.” In interview on 05/01/2025 at 10:00 AM, Registered Nurse (RN) 1 stated he worked 11:00 AM to 11:00 PM on 04/24/2025. He said the hospital did not have Internet and that not having the Internet available “could be a disaster situation.” RN 1 reported he was aware of the EMTALA requirements if a patient presented to the ED they were to be seen by a provider, stabilized and transferred or discharged as necessary. He further stated however, he was not aware of a patient being diverted on 04/24/2025. In interview on 05/01/2025 at 10:31 AM, the Unit Clerk stated she was aware of the EMTALA protocols that required all patients to be seen by a provider. She stated on 04/24/2025, the hospital was without Internet for CT scans “around 1:30 PM.” The Unit Clerk said the Internet being down would not be a disaster as far as patient care went; however, it could affect diagnostics and testing. She further stated a MVC with a rollover would indicate a CT would need to be done. In interview on 05/01/2025 at 10:40 AM, RN 2 stated she had not worked on 04/24/2025. She said the EMTALA requirements meant that patients arriving at the ED could not be turned away. RN 2 reported the Internet being down could possibly be a disaster for testing or imaging, but not for patient assessments. She stated a patient involved in a MVC with rollover would get a “trauma scan” to look for internal injuries, and the patient would be stabilized then transferred or discharged. RN 2 further stated if a patient made a choice to come to their hospital that was the patient’s right. In interview on 05/01/2025 at 10:53 AM, RN 3 stated the EMTALA requirements gave a patient the right to be seen when coming to the hospital. He stated a MSE was to be performed by a provider and hospitals did not have the right to refuse a patient. RN 3 said a MVC would be considered trauma, and a CT would be required. He further stated a trauma assessment would have to completed to see what was “going on” with the patient. In interview on 05/01/2025 at 11:14 AM, the ED Medical Director stated he been working in the ED on 04/24/2025 and heard the EMS call come in on the radio. He stated the call was related to a trauma MVC where the vehicle “flipped.” The ED Medical Director said the EMS staff were aware of the facility’s trauma diversion; however, brought P1 to “them anyway.” He stated he did not know why EMS brought P1 there when they knew we were on diversion. The ED Medical Director reported doing that had delayed P1’s care and EMS “wasted time” bringing the patient to their hospital knowing we were on diversion. He said even if the patient wanted to come there, EMS should not have brought him. The ED Medical Director stated EMTALA required provision of an MSE, stabilization and transfer to the appropriate level of care, but the hospital had been on diversion when P1 arrived. When the SSA Surveyor asked the ED Medical Director if P1 should have had a MSE, he did not answer question. In interview on 05/01/2025 at 1:40 PM, RN 4 stated she had worked on 04/24/2025 in the ED when the hospital was on diversion for trauma due to not having Internet available. She said the radiologist had not been there that evening and so there had been no one to read X-rays and CT scans with the Internet being down. RN 4 stated that had been the reason for the trauma diversion. She reported they continued seeing patients in the ED; however, she said she had no knowledge of any patients arriving to the ED and being diverted that day. RN 4 further stated the EMTALA rules required all patients to be seen by a provider. In a telephone interview on 05/02/2025 at 11:31 AM, the Chief Nursing Officer (CNO) /Vice President of Patient Care Services (VPPCS) stated she oversaw all nursing activities at the hospital. She stated a “Code Yellow” was considered a “disaster” situation, and when they did not have services available the ED Director was responsible for notifying EMS of that information. The CNO/VPPCS said she expected staff to follow the facility’s policies on EMTALA; however, she could not provide details regarding those policies as she did not have them (policies) in front of her. She reported she had no knowledge of P1 arriving at the ED and not being seen until she watched the video surveillance with the SSA Surveyor and the VPO. The CNO/VPPCS said she did not know that P1 had requested to come to their hospital. She stated a patient involved in a MVC would automatically get a head CT; however, she did not know what the protocol was. The CNO/VPPCS stated she would have to look at the protocols for when an MSE should be done as she was not familiar with them. She further stated she expected the hospital staff to follow their protocols and follow what the policy says. In interview on 05/02/2025 at 11:48 AM, the Chief Executive Officer (CEO) stated she was familiar with the EMTALA requirements and that an MSE was to be provided when patients presented to the ED. She stated the hospital had been on diversion at the time P1 was transported there. The CEO said EMS had been updated and were made aware when changes occurred. She reported EMS staff notified the ED that they were enroute there with P1, and when they arrived at the hospital, the ED Director notified them “we were on diversion.” The CEO stated EMS them transported the patient to another facility. She said with a “Code Yellow” the ED Director would have communicated with EMS when that was occurring. The CEO explained the hospital had been on diversion because their Internet was down and they did not have the ability to read a CT. She stated when the radiologist was “in house,” CT scans could be read, but when he was not “in house” without Internet they had no way to transmit those images. The CEO further stated the radiologist was contracted and “they” did not have the ability to make him stay past his assigned time. In interview on 05/02/2025 at 12:02 PM, the Vice President of Operations (VPO) stated with EMTALA requirements hospitals had an obligation to treat individuals and that meant providing a MSE, stabilization, and transfer if needed. She stated they knew that the radiologist would be leaving on 04/24/2025, and they normally converted to a virtual radiology service. The VPO reported however, the hospital had been on trauma diversion on 04/24/2025, due to their Internet being “down.” She said they had no way to transmit results of radiology tests. The VPO stated she was made aware the next day that P1 had been diverted to Fac 2. She further stated however, EMS had been notified and were aware we were on diversion.”